Costly Clarification

When Children's Hospital got word last week that the state Department of Health had finished an investigation into the recent death of one baby and the brain damage suffered by another, the hospital issued what seemed an "all clear" to the public. "Today," it said in a statement, "we received reports on three open investigations recently covered in the news media. After thorough investigations, the DOH reports that they found no hospital 'deficiencies.' This means that the policies, systems, and procedures at Seattle Children's meet their requirements for protecting patient safety." But as Children's acknowledged at the end of its statement, investigations continue and questions remain. The probe began after a tragic couple of weeks for Children's. Among the incidents: A newborn baby died Sept. 17 after being medicated en route to Children's in a hospital neonatal ambulance. On Sept. 19, an 8-month-old baby died after being given 10 times the proper dose of medication. And on Sept. 26, an adult emergency patient was wrongly injected with medication in a vein rather than a muscle. He recovered. DOH probers, in their announcement, concluded Children's "has effective, adequate systems to prevent patient harm in place. No 'deficiencies' in those systems were found." But that announcement wasn't referring to all three of the above cases. The death of the newborn was not part of the review, and is still being examined. "In that case," says DOH spokesperson Tim Church, "it's alleged a nurse gave medication without an order while the baby was being prepared for transfer to Children's." In the case of the 8-month-old, Church says, "investigators determined the child did receive an incorrect dose of calcium chloride five days before the child died. It's unknown whether that overdose contributed to the baby's death." The DOH cleared the hospital's systems and procedures in that case. But the state Medical Quality Assurance Commission and Nursing Care Quality Assurance Commission are still investigating the conduct of Children's staff in that case and others.